elderly hand fractures singapore 2015 rauma conference v2.0

Hand and Wrist Fractures

in The Elderly

Mr Vaikunthan Rajaratnam Senior Consultant Hand Surgeon

This work is licensed under a Creative Commons Attribution 4.0 International License.

I heard the old, old men say,“Everything alters

And one by one we drop away”.They had hands like claws, and their knees

Were twisted like the old thorn treesBy the waters

W B Yeats

Ageing Hand

age-related degenerative changes in the• musculoskeletal,• vascular, and • nervous systems. • a combination of local structural changes (joints, muscle,

tendon, bone, nerve and receptors, blood supply, skin, and fingernails) and more distant changes in neural control.

• accompanied by underlying pathological conditions (osteoporosis, osteoarthritis, rheumatic arthritis, and Parkinson's disease)

J Gerontol A Biol Sci Med Sci. 2003 Feb;58(2):146-52.The aging hand.

Carmeli E, Patish H, Coleman R.

Effects of aging on hand function.PARTICIPANTS:• Healthy, independent, young (n = 27, range 20-35 years) and older (n

= 28, range 65-79 years) subjects.• The decrease in the ability to maintain steady submaximal pinch

force was more pronounced in women than men.CONCLUSION:• Aging has a degenerative effect on hand function, including declines

in hand and finger strength and ability to control submaximal pinch force and maintain a steady precision pinch posture, manual speed, and hand sensation.

J Am Geriatr Soc. 2001 Nov;49(11):1478-84, Ranganathan VK, Siemionow V, Sahgal V, Yue GH, Cleveland

Effects of aging on adult hand function.

study was conducted examining relationships between prehension pattern type and frequency, hand strength, and performance time in functional tasks.

Four groups of 10 adults were selected by age and gender, ranging from 24 to 87 years. Subjects were asked to pour milk into a cup and remove money from a wallet while being videotaped. Statistically significant differences in age1. prehension pattern frequency,2. hand strength, 3. and performance time. Hand function seemed to remain stable until age 65 years, . After age 75 years, age differences in performance were most apparent.

Shiffman LM.Am J Occup Ther. 1992 Sep;46(9):785-92

The effects of strength training on finger strength and hand dexterity in healthy elderly individuals

strength training-improve finger strength. improve the hand function of less healthy elderly subjects.

Journal of Applied Physiology October 2008 vol. 105 no. 4 1166-1178

Halla B. Olafsdottir, et al,

• N = 585• Age 16 and

above• 2 groups >60 and

<60• N=34 vs n=551

THE EPIDEMIOLOGY AND DISTRIBUTION OF HAND FRACTURES IN SINGAPORE

Jin Xi Lim, Jia Jun Justin Boey, Jun Hao Tan, Alvin Chin Kwong Tan,Rajaratnam Vaikunthan

1 Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828

2 National University of Singapore, Singapore

Gender

Female Male0

10

20

30

40

50

60

70

80

90

100

11

89

5644

<60 >/= 60

Perc

enta

ge

Location/ circumstance of injury

Home Public Place Work RTA Assault/ Fight Sports Not recorded0

10

20

30

40

50

60

70

80

9 8

51

19

2 7 4

71

312

60 0

9

<60 >/= 60

Perc

enta

ge

Mechanism of Injury

Amputation

Axial L

oadCru

sh

Direct

impact

Hyper-e

xtensio

n

Flexio

nSh

arp

Not reco

rded

0

10

20

30

40

50

60

3 3

38

8 5 19

33

0 3

21

315

0 3

52

<60 >/= 60

Perc

enta

ge

No of Fractures

1 2 3 4 60

10

20

30

40

50

60

70

80

90

100

73

167 3 1

94

6 0 0 0

<60 >/= 60

Perc

enta

ge

Open/ Closed injury

Closed Open0

10

20

30

40

50

60

70

80

90

61

39

77

23

<60>/=60

Perc

enta

ge

Fracture distribution

<60 years old >/= 60 years old

DEMOGRAPHICS 40 cases

• GENDER Male: 17 ( 41.4% )Female: 23 ( 58.6% )

• AGE

Oldest: 101Youngest: 60Mean: 70.275

• RACE

Chinese: 28Malay: 3Indian: 9

• GAINFUL EMPLOYMENT Yes: 4No: 36

Gender

MaleFemale

Race

ChineseMalayIndian

Mean 73.60

Median 73.00

DOMINANT HAND INJURY

• HANDEDNESSRight: 29Left: 0Unknown: 11

• HAND INJURED

Dominant: 17Non-Dominant: 12Unknown: 11

Hand Injured

DominantNon-Dom-inantUnknown

GENESIS OF INJURY• LOCATION INJURY SUSTAINED

Home/ Nursing Home: 25Workplace: 4 (all those gainfully employed)Public Place: 5Others: 6

• MECHANISM OF INJURY

Crush Injury: 8Penentrating/Sharp Injury: 1Blunt Trauma : 1Hyperextension: 5Fall/Axial Load: 1Others/Unknown: 24

Crush

Injury

Blunt trau

ma

Fall/

Axial lo

ad0

5

10

15

20

25

30

Mechanism

Mechanism

Location

Home/Nurs-ing HomeWorkplacePublic PlaceOthers

FRACTURE PATTERNS• NUMBER OF FRACTURES

Single: 38Multiple : 2 ( both 2 each )

• FINGER INVOLVED

Thumb: 5Index: 4Middle: 3Ring: 6Little: 16Unknown: 6

• TYPE OF FRACTUREOpen: 8Closed: 30Unknown: 2

ThumbIndex

Middle

RingLitt

le

Unknown

0

4

8

12

16

Finger

Finger

Type of FractureOpen ClosedUn-known

MANAGEMENT

• Operative: 3 2 Plate & Screws 1 Interfragmentary screw

• Conservative: 37

# Metacarpal Base with extension to Shaft

5th Metacarpal Neck #

# Shaft of 5th Metacarpal

P1 Base # ring finger

P1 Base # ring finger – Post op

P1 Head intra-articular #

Tuft #s

Thumb P1 Base intra-articular #

• 12% had a superficial infection (all treated with transverse pinning with wires left exposed);

• 39% had some impairment in skin sensation; 29% reported cold intolerance; and

• 10% had other complications.

Surgical intervention - only when one is sure of giving better results than conservative management

My view

• Treat as with all patients – implant evolution• Discuss options and outcomes• Manage physiological age not chronological• Pre existing symptomatic OA – consider fusion

and replacement• Manage osteoporosis• High demand elderly ?

Thank you